Forms Library

Forms produced by the Wisconsin Department of Health Services are available for downloading and printing from this site. If a form is not available electronically, you will be provided instructions for requesting a paper copy. If you are searching for a form number that does not start with the letter "F," just enter the number you have available and you will get a better search result. Example, looking for DDE-2539? Enter "2539" in the Search Forms field below.

The Division of Health Care Access and Accountability (DHCAA) and Division of Long Term Care (DLTC) have combined into the Division of Medicaid Services (DMS). When searching for forms by Division, please use the new acronym.

Assigned Number Title Division Other Locationsort descending
F01454G IRIS Program Withdrawal Letter – Cancelled DMS
F-02639 Time and Task Pretest DPH
F-00258 Functional Eligibility Screen - Mental Health and AODA (Co-Occurring) Services DCTS
F-01253 FoodShare Employment and Training (FSET) - Appointment Final Notice DMS
F-01149 Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements DMS
F-62372 Community Based Residential Facility (CBRF) Resident Satisfaction Evaluation DQA
F-13150 Wisconsin Medicaid Confidential or Alternative Communication Request DMS
F-01293C Fiscal Employer Agent (FEA) Change Effective Date Letter DMS
F-00987B EMS Service Operational Plan Advanced Skills Addendum (Advanced) DPH
F-02536 Nursing Home: Waiver or Variance Request DQA
F-11083 Prior Authorization/Brand Medically Necessary Attachment (PA/BMNA) DMS
F-44614B AIDS/HIV Drug Insurance Premium Subsidy Program and Drug Assistance Program Application/Recertification Part B - Physician Portion DPH
F-00067 Program Review Outcome / Activity Person-Centered Field Review Report DMS
F-01254 FoodShare Employment and Training (FSET) - Employment Plan (EP) Appointment DMS
F-19002 Request to Reduce QUEST Card Balance DMS
F-01153 Breast Pump Order DMS
F-62373 Resident Evacuation Assessment DQA
F-13151 HIPAA Privacy Amendment Request DMS
F-01293D Participant Fiscal Employer Agent (FEA) – Transfer Checklist DMS
F-00987C EMS Service Operational Plan Advanced Skills Addendum (First Responder) DPH
F-02564 Mental Health or Substance Use Treatment Provider: Initial Certification Application DHS 40 and DHS 50 DQA
F-11088 Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA) DMS
F-01660 Emergency Medical Staff Patient Tracking Pilot Program Commitment, Wisconsin Healthcare Emergency Preparedness Program (WHEPP) DPH
F-00676 Youth Transition Pretest DPH
F-02491 FoodShare Buy and Make Food Separately DMS
F-10190 Medicaid Issuer of Annuity - Notice of Obligation DMS
F-00989i Instructions for Completing Wisconsin's Individualized Family Service Plan (IFSP) DMS
F-00512 Mental Health Day Treatment Program Initial Certification Application - DHS 61.75 DQA
F-43006 Health Care Employer Assurance for J-1 Visa Waiver Applications DPH
F-21353 Children's Long-Term Support Waiver High-Cost Request DMS
F-10098 Medicaid Member Asset Allocation Notice DMS
F-01442G IRIS Program Disenrollment Letter – Non-Spending DMS
F-02314A Wisconsin Tuberculosis (TB) Risk Assessment Questionnaire Screen for Wisconsin Public School Employees DPH
F-00367 Functional Eligibility Screen for Children's Long-Term Support Programs DMS
F-01345 Special Care Environment Working Document DPH
F-01228 WISEWOMAN Follow-up Assessment: LSP/HC Complete DPH
F-00195 IDEA (Individuals with Disabilities Education Act) State Complaint - WI Birth to 3 Program DMS
F-21334 Encounter New User Request DMS
F-02122 Opioid Crisis State Targeted Response Program Funding Request DCTS
F-00044 User Agreement for System Access DES
F-01206A IRIS One-Time Expense Vendor Bid Comparison DMS
F-62641 Hospice Inpatient Symptom Management and Respite Contract or Agreement Review DQA
F-62680A Home Health Agency (HHA): Clinical Record Review (State & Federal) DQA
F-16024 FoodShare Notice of Disqualification DMS
F-01955 Wisconsin EMS Training Record Critical Care Paramedic Refresher Record DPH
F-01068H General Pediatric Clinic - 18 Month Visit DMS
F-62233 Hospice Personnel Record Review DQA
F-02110D RCAC: New Provider Certification / Registration Application Checklist DQA
F-13024 Medicaid Purchase Plan Premium - Employer Wage Withholding Information and Instructions DMS
F-01761 Intoxicated Driver Program Self-Evaluation DCTS

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Last Revised: March 26, 2019